Download Foreword - Lincolnshire County Council

Foreword
We welcome the opportunity to work in collaboration with our colleagues in NHS Lincolnshire,
Lincolnshire County Council, district councils and the third sector to design and deliver this
strategy.
A desire to improve services and change the way we deliver them for the benefit of local people
is the driver behind the Lincolnshire Prevention Strategy.
The production of this strategy represents the recognition of the value of investment in
preventive services to delay entry into social care and health services and the importance of the
promotion of well being and community involvement for all our citizens.
Across Lincolnshire we will face many challenges over the coming years as a result of the
projected increase in the number of older people and people with long term health conditions as
well as the increasing pressure due to an expected reduction in funding from central
government.
The introduction of this strategy and supporting action plans with the continued focus on the
engagement of voluntary and community groups to support delivery of universal and community
wellbeing services represents a pragmatic and exciting response for Lincolnshire’s citizens.
Introduction
This three year strategy sets out the approach to demonstrating the value of preventive services
in delaying peoples need for costly health and social care services at the same time as
improving people’s quality of life. As such it covers all adults in Lincolnshire.
It builds on the existing strengths of the service, because prevention is already an important
component of much of what organisations in Lincolnshire deliver. However the strategy seeks to
accelerate the agenda and establish new directions, in partnership with other agencies, for
developing further on the solid foundations we have in place.
The development of this strategy has been a shared one across health, social care, housing
and the Third Sector.
We have engaged with staff, patients, service users, carers and members of the community and
what they have told us is that they want to be able to live healthy and active lives for as long as
possible but that there are times when they will need a little bit of help to do this.
At these times they want services that are readily available and easily accessible which are
delivered in a joined up way so as to avoid having to tell the same story to numerous
organisations in a bid to get the help they need.
Taking this as our starting point we have, therefore, identified two core overarching outcomes
for the strategy and for prevention services across Lincolnshire as follows:
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
People are well informed about the options available to them through advice and
information when faced with potential support needs; and
Through joined up early intervention, more people are helped to avoid a crisis that could
lead to unnecessary admissions to hospital or longer term care.

In delivering services to meet these outcomes, via aligning preventive services to this strategy,
we believe that local organisations will be able to meet the following two objectives:

Demonstrate the success of investment in prevention to inform ongoing financial planning
decisions; and
Ensure that effective joint working across the whole system makes the most efficient use
of investments in preventive services by maximising their impact.

We need to make sure that we target people with the right services at the right time and in order
to do this we feel there are four key points in people’s lives where they may benefit from
services being better targeted and more joined up. These four key trigger points are:




Ceasing employment (either by retirement or loss of a job)
Changing housing situation (such as moving home or having to sell your home)
Suffering a bereavement (which maybe a partner, close family relative or family carer)
Health concerns (this could be a deterioration in health or a diagnosis of a long term health
condition)
Q1.
Is the content of the strategy factually correct?
Q2.
How do you see the outcomes and objectives of this strategy assisting you in
meeting your organisations strategic objectives or service planning intentions?
Q3.
Are there other ‘trigger points’ where you feel it would be useful for us to focus
prevention services in order to prevent or delay the need for unnecessary
admissions to hospital or longer term care services?
Defining Prevention
Government has identified the following definition of prevention in a bid to support Local
Authorities and NHS organisations to target their preventive services more effectively:
Primary Prevention -
Provision of universal access to good quality information, supporting
safer neighbourhoods, promoting health and active lifestyles, etc
Secondary Prevention - Identification of individuals at risk of specific health conditions or
events (such as strokes or falls) or those who have existing low level
care needs
Tertiary Prevention Maximise people’s independence through interventions such as
rehabilitation and joint case management of people with complex
needs.1
1
Department of Health (2008), Making a strategic shift to prevention and early intervention
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The focus of the work to develop this strategy has been on primary and secondary prevention
with Health and Social Care working separately on tertiary prevention via the development of reablement services and the review of intermediate care.
However the course of someone’s journey through prevention services is not necessarily a
straight line with a person moving through the levels of preventive services in a successive way.
For example, a person may still benefit from good quality information (primary prevention) whilst
they are in or being discharged from Intermediate Care (tertiary prevention). This concept is
perhaps best demonstrated by the diagram below:
Source:
HM Government (2009), New Horizons: A shared vision for mental health
Q4.
Is it right for the focus of the strategy to be around primary and secondary
prevention?
Q5.
How do we ensure that this prevention strategy supports people across the whole
system to help delay the deterioration of people’s conditions when already in
services at the same time as delaying or preventing people from needing services
in the first place?
Making the case for prevention
Over the course of the last 10 years more and more money has been spent on fewer people
with greater care needs. This is demonstrated in Lincolnshire by the following graph which
shows net spend on adult social care against the number of people receiving services.
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40,000
180,000,000
35,000
160,000,000
140,000,000
30,000
120,000,000
25,000
100,000,000
20,000
80,000,000
15,000
60,000,000
10,000
40,000,000
5,000
20,000,000
0
Total net expenditure on adult social
care
Number of people receiving help from
adult social care
Trend of net expenditure against number of adult social care
recipients in Lincolnshire 2000/01 - 2007/08
0
2000/01
2001/02
2002/03
2003/04
Users
2004/05
2005/06
2006/07
2007/08
Expenditure
Source: ‘Personal Social Services Expenditure and Unit Costs’ and ‘Community Care Statistics: Referrals,
assessments and packages of care for adults’, NHS Information Centre
Over the coming 20 years there is expected to be an unprecedented increase in the number of
older people as well as people requiring help due to diagnosis of certain health conditions. This
is demonstrated in the graph below which sets out expected increases in Lincolnshire compared
with the expected increases across England over the same timeframe. The difference between
the estimated increase across England and Lincolnshire is significant ranging from a 25%
difference to a 30% difference.
Estimated increase in Lincolnshire and England between 2008 and 2025
of certain conditions for people aged 65 and over
90.0%
78%
80.0%
71%
70.0%
64%
62%
62%
60.0%
51%
50.0%
40.0%
39%
England
42%
37%
37%
Lincolnshire
30.0%
20.0%
10.0%
0.0%
Limiting Long Term
Illness
Depression
Source:
Falls
Social care
recipients
Dementia
Projecting Older People Population Information System (POPPI)
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Set out in the second graph below is data relating to expected increases of certain long term
health conditions between 2007 and 2027.
Predicted increase in number of people on their GP register
with long term health conditions 2007 - 2027 - Lincolnshire
90.00%
80.00%
75.2%
79.2%
77.7%
70.4%
70.00%
59.6%
55.4%
60.00%
50.00%
46.4%
40.00%
30.00%
20.00%
10.00%
0.00%
Hypertension
Chronic Heart
Disease
Stroke
Cancer
COPD
Diabetes
Total
Source: NHS Lincolnshire
In summary the future holds two key challenges for all organisations working within or on behalf
of local health, social care and housing organisations as follows:
1. An increase in demand for health and social care associated with an ageing population
and changing expectations; and
2. A reduction in the growth of public funding for health and social care.2
The above information summarises the position if we were to do nothing different in the
future and to continue to deliver services in the same way as we currently do.
Clearly this is not an option given the scale of the potential increases in demand for services
over the coming years and the potential reduction in the growth of public funding.
Additionally to the local picture set out above there has also been an emerging policy agenda at
a national level over the past five years to drive health and social care organisations to work
together in the pursuit of delivering more joined up services that support people to remain living
independent healthy lives for as long as possible.
The clearest examples of this are ‘Our health, our care, our say’ (DH, 2006) and the NHS Next
Stage Review ‘High Quality Care for All’ (DH, 2008) both of which include a central tenet to
2
Department of Health (2010), Improving care and saving money: learning the lessons on prevention and early intervention for older people
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drive the whole system towards ensuring people lead healthier lifestyles in order to prevent ill
health and remain living independently for longer. Coupled with this World Class
Commissioning (DH 2007) recognises that to tackle health inequalities and to ensure people
live healthier lives for longer it is critical that local services, both those who use services as well
as those who commission them, work together to design, develop and deliver high quality
integrated services.
Q6.
What arrangements and/or services do we need to put in place in the next 12
months in order to prepare for the challenges ahead in terms of increasing levels
of need and decreasing growth in public funding?
What we are currently doing
Currently in Lincolnshire there is a range of “preventive” work being undertaken across public,
private and third sector organisations which as individual services are having a real impact on
people’s ability to remain living independently and their quality of life.
The table below shows the level of investment in prevention expected in 2010/11, where we
have been able to identify it, across the health and social care system:
Organisation
Lincolnshire County Council
NHS Lincolnshire
TOTAL
Amount Invested
£
7,660,443.22
£
7,910,289.00
£
15,570,732.22
Source: Survey of NHS and Lincolnshire County Council
commissioners , 2009
It is worth mentioning that whilst many prevention services are funded from ‘core’ service
budgets they will increasingly come under pressure to demonstrate their effectiveness due to
the financial pressures on public sector budgets, which are widely considered to be significant
over the coming years.3
Development of prevention services has also tended to be driven in isolation within
organisations and so many of these interventions are lacking in scale and scope to deliver the
magnitude of improvement which will be required to address the increase in demand versus the
reduction in growth of public funding.
In order to deliver against the two overarching objectives set out in the introduction to this
strategy there will be a need to ensure that effective joint working across organisational
boundaries makes the most efficient use of current investments in preventive services by
maximising their impact. This coupled with an agreed way of measuring the impact that
prevention services are having on reducing or delaying peoples need for health and social care
services will ensure that we are able to provide evidence for how services might be configured
in the future around ensuring people lead healthier, independent lifestyles for longer.
3
Free personal care bill is expected to have a significant net additional cost to the county council if enacted. The current best estimate of the
county council is that over the next 3-5 years there will be a reduction in expenditure of between 25-30%.
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Q7.
Are there examples you are aware of where existing prevention services have been
commissioned and delivered in a fully joined up way with pooled resources and
shared management arrangements?
Q7a. If yes, what have been the constraints and drivers for making these services work
effectively?
Priorities for change
A large part of our work on developing this strategy has been to identify some key short to
medium term priorities to be taken forward over the next three years.
However in order to deliver a longer term strategic shift in the way services are delivered
more fundamental and challenging decisions need to be taken about integration across
organisations.
The Audit Commission has recently highlighted that it is transformational change rather than
incremental change which will enable us to meet the challenges set out earlier in this strategy.4
Integration of service delivery, finance, commissioning and performance can be ‘individuallycentred’ or ‘system-centred’. Recent work by the Institute for Public Policy Research (IPPR) has
suggested that the best way to create a more responsive and financially effective model of
delivering services is to combine both of these approaches.
Individual centred approaches promote enhanced citizenship in the planning and delivery of
public services where as system centred approaches are driven by greater financial and
operational efficiency.
Recent thinking at a national level has also focused on basing integration around the
establishment of ‘single issue budgets’ and long-term health conditions are a particular area of
service delivery where it is difficult to draw the distinction between the roles of health and social
care. 5
Due to the key relationship between this prevention strategy and the work on long term health
conditions in the county there may be potential benefits in delivering prevention services under
a single joined up budget across health and social care, possibly including district council
housing services and the third sector within this structure as well.
The Audit Commission has also recently highlighted that where integration has happened it has
tended to focus on the system-centred approach (despite the fact that most partnerships would
consider improved outcomes and user experience for people to be the primary driving force
behind integration). This is in part due to the fact that incompatible information and finance
systems lead the integration to focus on systems and processes. Conversely this is often at the
expense of the initial driver for integration, i.e. improved experience and outcomes for people.6
4
Audit Commission (2010), Under Pressure: Tackling the financial challenge for councils of an ageing population
Institute for Public Policy Research (2010), Integrating Health and Social Care Budgets: A case for debate
6
Audit Commission (2009), Means to an end: Joint financing across health and social care
5
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Set out below are some priority themes for the strategy to take forward but this needs to be
delivered within a system which works in an effective and fully joined up way. With this in mind
we are proposing to pull together preventive services across sectors under one pooled budget
in order to share more effectively the resources we have available in terms of commissioning,
finance, performance and service delivery. This is demonstrated by figure 1 below.
POOLED PREVENTION BUDGET
NHS
Lincolnshire
Lincolnshire
County Council
Finance
District Councils
Performance
Third Sector
Commissioning
Service Delivery
Fig 1: Model of Integration to deliver Prevention Strategy
Q8.
How do you think service integration can be utilised for delivering this strategy?
The following are the principles upon which ongoing assessment of the priorities should be
measured:




the approach should be scaleable – both Geographically, but also across other health
conditions;
there has to be evidence and confidence in the evidence that the prevention strategy is
delivering and will continue to deliver reduction in demand for other more expensive
services;
ease and speed of implementation is critical in order to meet the most immediate
financial pressures;
developments are sustainable in terms of the ongoing funding available if the evidence
is compelling that prevention services are delaying peoples need for more costly care
services; and
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
Q9.
evidence of better outcomes for citizens through quality of life measurements.
Do you believe the principles we have set will support the delivery of the overall
outcomes and objectives of the strategy?
With the above principles in mind it has become clear from our discussions with partners and
the community themselves that the priority areas for our attention are as follows:
Theme One – Joined Up Working
We have some excellent prevention services in Lincolnshire already such as the First Contact
referral scheme and the Frail Older Persons Pathway. Bringing these together, along with Older
People’s services within Supporting People and the adult social care Bridge prevention service
and the Falls Prevention Service, will create an approach to prevention services that will build
upon the existing work at the same time as affording the opportunity to scale these up so
they are able to deliver far greater and better outcomes then the sum of their parts.
Not only does this have the potential to deliver improved outcomes but will also help us to
address the issue of duplication by ensuring services are delivered in a more joined up way.
Each of the services included here are funded from different sources, under different
agreements and for different lengths of time and so any potential to join these services up will
need to undertaken with this in mind.
Evidence and Benefits
In order for an older person to remain fit and healthy in Lincolnshire there are potentially 50
different services that could support them for which they would have to complete 8 application
forms, go through 15 entitlement checks and be assessed 24 times. There are therefore a
number of reasons why we feel we should join up existing services as follows:

Existing services are many and varied and would appear to duplicate effort by virtue of the
number of different assessment and entitlement checks there are of which a significant
number will be asking very similar questions of people;

Feedback from the community has been that they want services joined up to avoid having
to tell the same story numerous times; and

There are potential financial advantages to working more efficiently with what we already
have.
Theme Two – Better Targeting of Services
Better sharing of information will help to monitor the performance of prevention services and
track success of existing services as well as the common causes of referral to reactive services.
This will enable targeting of further prevention. It also enables prediction of levels of risk to
people needing hospital or social care services and hence better targeting of prevention
services can be made.
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Better targeting of preventive services, and understanding of the effectiveness of
ongoing prevention measures, will inform the move towards achieving a strategic shift in
the way services are funded towards prevention.
The success of this level of targeting can only be achieved by adopting a more systematic but
measured approach to sharing information about our mutual customers, within the existing legal
framework. Doing so will enable us to pro-actively push services out to people at times when
they need and will benefit most from local services working together. This requires a level of
commitment across health and social care as well as from GPs, district councils and other key
local service providers.
Evidence and Benefits
When looking at existing prevention services it is clear that many services target people with
similar needs and in order to achieve similar outcomes. Where targeting takes place it is linked
to the organisation commissioning the service, hence NHS services tend to target people based
on clinical needs and social care services target based on social care needs. The reasons why
we think that better targeting will support better outcomes is:

Capacity planning based on risks which combine health, social care and housing data has
the potential to reduce hospital and care admissions. This is due to the ability to use
aggregate forecast risks, derived from wider sets of service data, to profile optimum
service packages to delay or prevent development of greater care needs

Once risks have been identified then targeted campaigns will improve peoples ability to
manage their own care by creating service delivery campaigns based on aggregation of
individual citizen data

Personalised service campaigns will improve choice and personalisation of care services
by making service recommendations outside of campaigns to enable service teams to
directly intervene with individuals at risk

Using aggregate service data will improve the effective use of resources across the whole
system. Creating population level views of the risks associated with people needing high
cost care services will deliver evidence to inform effective commissioning and financial
planning.
Theme Three – Tele-care
The case for investing in tele-care is gathering evidence nationally; whilst local investment and
achievements to date have been commended. This theme is about building further on this
success to expand the scope of tele-care services beyond their current focus on those who
have eligible care needs to the whole population. We are proposing to enable people to
understand their needs earlier and purchase tele-care equipment for themselves. This will
allow people with low level support needs and their families to have peace of mind that they are
able to remain living safely and independently at home for as long as possible.
As part of this theme the opportunities to streamline tele-care monitoring across the county will
also be explored, which may offer some short-term financial benefits. As with theme one we
know that these services are currently delivered within existing contractual arrangements and
so any potential changes will likely need to be phased in.
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Evidence and Benefits
The evidence for the effectiveness of telecare services in delaying or preventing needs
deteriorating is still developing however it is viewed nationally as a having the potential to
deliver significant efficiencies across health and social care services if it is mainstreamed.7
Locally we have found that there is a belief that widening the scope of telecare services
(particularly in the support of self care by way of supporting people to access such services
regardless of need) might improve the potential for it to have an impact on delaying peoples
need for other health and care services. As part of widening the access to such services
feedback has also been received that this will require a review of how such services are
monitored and responded to (particularly out of hours).
Theme Four – Tele-Health
There is an emerging evidence base for investment into tele-health to help give confidence to
sufferers of long term health conditions that any issues with their condition will be picked up.
This theme will initially focus on one long term health condition and in one geographic
area to ensure that action learning can be undertaken before rolling the service out
further to other areas and to other specified health conditions.
It is proposed that the initial focus will be in the Skegness area of East Lindsey with the potential
to target people with diabetes. This theme will also support the self care work which is being
undertaken in Lincolnshire by enabling people being diagnosed with diabetes to access support
and information to help them to support and manage their condition themselves.
Evidence and Benefits
Many of the reasons and the evidence for adopting a more strategic approach to telehealth
services are the same as for telecare above. In terms of service integration and delivering
services efficiently we have also heard from partners that there may be benefits in discussing
how financing and management of telecare and telehealth services can be joined up across
health, social care and housing service areas.
Q10. Do you think the four themes for the strategy will deliver the evidence needed to
make a strategic shift in the centre of gravity of spending towards prevention?
Making it happen
In supporting the delivery of this strategy there is an opportunity for health, social care, housing
and other partners to come together to address the hopes and aspirations of people living in
Lincolnshire to live healthy lives for longer.
7
Department of Health (2009), Use of Resources in Adult Social Care
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During 2010/11 there is the very real potential for short term investments in prevention to start
to deliver real benefits for a range of organisations across Lincolnshire and, more importantly, to
individuals living and working in the county.
The audit commission puts it as follows:
“2010/11 is the final year of the 2007 three-year public spending settlement.
Councils can use short-term certainty to help them plan for tighter financial
settlements, and an environment where every service and activity will be under
scrutiny to deliver more for less”8
In Lincolnshire, additional to the investments identified elsewhere in this strategy which could
potentially be pooled into one prevention budget, there are some short term possibilities to
finance the strategy implementation as follows:
Funding Source
Potential Amount Available
Health and Wellbeing Fund
£2,000,000
Adult Social Care
£500,000
Putting People First Transformation Grant
To be determined
Lincolnshire Improvement and Efficiency Partnership
To be determined
We will set out in our action plan the key themes identified in this strategy and the actions we
will take to ensure we deliver against these themes. We will also detail the resources required to
deliver those actions and the funds which will be used to support the delivery.
8
Audit Commission (2010), Under Pressure: Tackling the financial challenge for councils of an ageing population
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